Carter Review - final report and recommendations

Photo of Lord Carter

The final report and recommendations of the Carter Review were published today (5 February), with specific workforce issues among its 15 overall recommendations. 

Unwarranted variation: A review of operational productivity and performance in English NHS acute hospitals details the conclusions of Lord Carter’s review into productivity within hospitals across England, to ensure the NHS gets the best value from its annual budget.

The report identified significant and unwarranted variation in costs and practice which, if addressed, could save the NHS £5bn. 

Of these savings up to £2bn comes from the workforce budget, through: 

  • better use of clinical staff
  • reducing agency spend and absenteeism
  • adopting good people management practices.
The report acknowledges that although there is exceptional practice already happening in the NHS, the overall average is not sufficient and more needs to be done to bring poor performance up to meet the best.  Employers and workforce leaders play a crucial role in this.  

Overall culture of the NHS 

The report acknowledges the vital role of people management, the daily contribution of NHS staff and the need to see workforce as more than a cost.  

It makes some critical points about the current culture of the NHS, which it says ‘directly affects motivation and morale, and the degree to which people are prepared to give their best at work.’

Delivering the recommendations requires good working relationships throughout organisations, and high quality staff engagement. 

Model hospital

The report looked at good practice in the NHS and elsewhere and developed the concept of a model hospital. Based on data on successful organisations, it has identified nine practices that are the key elements in developing a successful organisation. Implementing the practices of the model hospital would, the report claims, achieve the £5bn in savings.

Values-based behavioural framework Developing a values-based behavioural framework, agreeing at the outset the trust’s underpinning values
Patient-centred organisation Moving towards a patient-centred organisation design – ensuring structure, workflow and resource allocation is designed around the patient through each stage of their hospital journey.
Structural improvements Adopting basic structural improvements – ensuring adherence to best practice management spans and layers, consistency of roles, and defining clearly individual accountabilities and decision rights
Leadership strategy Developing a board-sponsored leadership strategy, based on business need and a clear set of expectations, and encompassing all leaders from board to front line
Operational management process
Implementing a comprehensive operational management process that drives operational performance, cost reduction, increased efficiency and continuous improvement
Adopting the model hospital dashboards with metrics that provide a balanced view of patient, people and financial performance 
Individual performance management system
Introducing an individual performance management system for appraising both task and behavioural performance for every individual in the trust, including a range of feedback mechanisms and linking this to consequences including reward, development, career progression
Building engagement across all occupational groups – harnessing the ideas and viewpoints of everyone in the trust, paying particular attention to clinical engagement and the role of the clinical leader
Colleague opinion survey
Repurposing the colleague opinion survey – reflecting more appropriately targeted questions and surveying sections of the workforce on a rolling monthly or bi-monthly basis to deliver a more timely pulse of people’s views, and using the outcomes as a key metric in all managers’ performance appraisals.

Workforce issues at a glance

People management practice

The report argues that the variation in people management practice across the NHS is holding back productivity improvement and that significant gains could be made by bringing the poorer performing organisations up to the level of the average. It contends that relying on regulation and inspection alone will not achieve this and recommends that a national support team be set up to support implementation. 

Better use of nursing staff  

The Carter team worked with a group of 26 directors of nursing, looking at best use of nursing staff. They identified a wide variation in practice and will therefore be developing guidance on how to improve productivity, reduce absences, manage the need for bank and agency staff and review new nursing roles. 

Setting staffing levels 

The team looked at the issues around setting appropriate staffing levels. It concluded that current setting systems are not a good guide and recommends a new approach to provide a single consistent way of recording and reporting deployment of staff working on inpatient wards/units – Care Hours Per Patient Day (CHPPD). 
The report argues that CHPPD gives a more accurate view of the availability of staff and overcomes the limitations of the fixed staff ratios formula approaches. NHS Employers will be working with the National Quality Board to assess the idea of the CHPPD. 


The report recommends extension of e-rostering as a means of ensuring staff are deployed in the most productive way.

Commenting on the report, Danny Mortimer said:

“Lord Carter’s review rightly recognises that engaging all NHS staff around the efficiency challenge has a powerful effect in driving productivity and efficiency ,and can significantly improve standards of care. Excellent initiatives such as the streamlining programme around recruitment, which began in London and has been extended to other areas of the country, have already shown good results that bring benefit to patients and reduce costs. 

“The report outlines efficiencies that can be made in hospitals but efficiency savings also need to be identified across all areas of the NHS. Care must be taken to recognise local innovation, but we also need to learn from each other to minimise variation in the services we provide to local people.

“The NHS accepts the challenge set by Lord Carter to make the best use of the insights, talents and expertise of our people to improve patient care."

NHS Employers and the NHS Confederation have a range of resources, showcasing existing good practice in the NHS and supporting organisations to share with and learn from each other. You can find these in the related links to the right of this page. 

The headline findings of the full report are summarised on the NHS Confederation website.

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